Pelvic inflammatory disease

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Pelvic inflammatory disease

Drawing showing the usual sites of infection in pelvic

inflammatory disease

Classification and external resources

Specialty Gynecology

ICD-10 N70 -N77

ICD-9-CM 614-616

DiseasesDB 9748

MedlinePlus 000888

eMedicine emerg/410

Patient UK Pelvic inflammatory disease

MeSH D000292
 Pelvic inflammatory disease or pelvic inflammatory disorder (PID) is an infection of the
upper part of the female reproductive system namely the uterus, fallopian tubes, or the ovaries.
[1]
 Often there may be no symptoms.[2] Signs and symptoms, when present may include lower
abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, or irregular
menstruation.[2]Untreated PID can result in long term complications including infertility, ectopic
pregnancy, chronic pelvic pain, and cancer.[1][3][4]
The disease is caused by bacteria that spread from the vagina and cervix. [5] Infections
by Neisseria gonorrhoeae or Chlamydia trachomatis are present in 75 to 90 percent of cases.
Often multiple different bacteria are involved.[1] Without treatment about 10 percent of those with
a chlamydial infection and 40 percent of those with a gonorrhea infection will develop PID.[1]
[6]
 Risk factors are similar to those of sexually transmitted infections generally and include a high
number of sexual partners and drug use. Vaginal douching may also increase the risk. The
diagnosis is typically based on the presenting signs and symptoms. It is recommended that the
disease be considered in all women of childbearing age who have lower abdominal pain. A
definitive diagnosis of PID is made by finding pus involving the fallopian tubes
during surgery. Ultrasound may also be useful in diagnosis.[1]
Efforts to prevent the disease include not having sex or having few sexual partners and
using condoms.[7] Screening women at risk for chlamydial infection followed by treatment
decreases the risk of PID.[8] If the diagnosis is suspected, treatment is typically advised.
[1]
 Treating a woman's sexual partners should also occur.[8] In those with mild or moderate
symptoms a single injection of the antibiotic ceftriaxone along with two weeks of doxycycline and
possibly metronidazole by mouth is recommended. For those who do not improve after three
days or who have severe disease intravenous antibiotics should be used. [9]
Globally about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in
2008.[6] The number of cases of PID however, is not clear.[10] It is estimated to affect about 1.5
percent of young women yearly.[10] In the United States PID is estimated to affect about one
million people yearly.[11] A type of intrauterine device (IUD) known as the Dalkon shield led to
increased rates of PID in the 1970s. Current IUDs are not associated with this problem after the
first month.[1]

Contents
  [hide] 

 1 Signs and symptoms

 2 Cause
o 2.1 Bacteria involved
 3 Diagnosis
o 3.1 Differential diagnosis
 4 Prevention
 5 Treatment
 6 Prognosis
o 6.1 Complications
 7 Epidemiology
 8 References
 9 External links

Signs and symptoms[edit]

Illustration of pelvic inflammatory disease

Symptoms in PID range from none to severe. If there are symptoms, then fever, cervical motion
tenderness, lower abdominal pain, new or different discharge, painful
intercourse, uterine tenderness, adnexal tenderness, or irregular menstruation may be noted. [1][2]
[12][13]

Other complications include endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis,

periappendicitis, and perihepatitis.[14]

Cause[edit]
Chlamydia trachomatis and Neisseria gonorrhoeae are usually the main cause of PID. Data
suggest that PID is often polymicrobial. [14]Isolated anaerobes and facultative microorganisms
have been obtained from the upper genital tract. N. gonorrhoeae has been isolated from fallopian
tubes, facultative and anaerobic organisms were recovered from endometrial tissues. [15][16]
The anatomical structure of the internal organs and tissues of the female reproductive tract
provides a pathway for pathogens to ascend from the vagina to the pelvic cavity thorough
the infundibulum. The disturbance of the naturally occurring vaginal microbiota associated
with bacterial vaginosis increases the risk of PID.[15]
N. gonorrhoea and C. trachomatis are the most common organisms. The least common were
infections caused exclusively by anaerobes and facultative organisms. Anaerobes and facultative
bacteria were also isolated from 50 percent of the patients from
whom Chlamydia and Neisseria were recovered; thus, anaerobes and facultative bacteria were
present in the upper genital tract of nearly two-thirds of the PID patients. [15] PCR and serological
tests have associated extremely fastidious organism with endometritis, PID, andtubal factor
infertility. Microorganisms associated with PID are listed below. [15]
Bacteria involved[edit]

 Chlamydia trachomatis
 Neisseria gonorrhoeae
 Prevotella spp.
 Streptococcus pyogenes
 Prevotella bivia
 Prevotella disiens
 Bacteroides spp.
 Peptostreptococcus asaccharolyticus
 Peptostreptococcus anaerobius
 Gardnerella vaginalis
 Escherichia coli
 Group B streptococcus
 α-hemolytic streptococcus
 Coagulase-negative staphylococcus
 Atopobium vaginae
 Acinetobacter spp.
 Dialister spp.
 Fusobacterium gonidiaformans
 Gemella spp.
 Leptotrichia spp.
 Mogibacterium spp.
 Porphyromonas spp.
 Propionibacterium acnes
 Sphingomonas spp.
 Veillonella spp.[15]
 Mycoplasma genitalium[16]
 Mycoplasma hominis
 Ureaplasma spp.[14]

Diagnosis[edit]

Mucopurulent cervical discharge seen on a Q-tip

Micrograph of salpingitis – a component of pelvic inflammatory disease. H&E stain.

Upon a pelvic examination, cervical motion, uterine, or adnexal tenderness will be experienced.

[5]
 Mucopurulent cervicitis and or urethritismay be observed. In severe cases more testing may be
required such as laproscopy, intra-abdominal bacteria sampling and culturing, or tissue biopsy.[14]
[17]

Laproscopy can visualize "violin-string" adhesions, characteristic of Fitz-Hugh–Curtis

perihepatitis and other absesses that may be present.[17]
Other imaging methods, such as ulstrasonography, computed tomography (CT), and magnetic
imaging (MRI), can aid in diagnosis.[17]Blood tests can also help identify the presence of infection:
the erythrocyte sedimentation rate (ESR), the C-reactive protein (CRP) level, and chlamydial and
gonococcal DNA probes.[14][17]
Nucleaic acid amplification tests (NAATs), direct fluorescein tests (DFA), and enszyme linked
immunosorbent assays (ELISA) are highly sensitive tests that can identify specific pathogens
present. Serology testing for antibodies is not as useful since the presence of the
microorganisms in healthy people can confound interpreting the antibody titer levels, although
aniitbody levels can indicate whether an infection is recent or long term. [14]
Definitive criteria include histopathologic evidence of endometritis, thickened filled Fallopian
tubes, or laparoscopic findings. Gram stain/smear becomes definitive in the identification of rare,
atypical or and possibly more serious organisms.[18] Two thirds of patients with laparoscopic
evidence of previous PID were not aware they had PID, however even asymptomatic PID can
cause serious harm.
Laparoscopic identification is helpful in diagnosing tubal disease, a 65 percent to 90
percent positive predictive value exists in patients with presumed PID.[19]
Upon gynecologic ultrasound, a potential finding is tubo-ovarian complex, which
is edematous and dilated pelvic structures as evidenced by vague margins, but
without abscess formation.[20]
Differential diagnosis[edit]
A number of other causes may produce similar symptoms including appendicitis, ectopic
pregnancy, hemorrhagic or ruptured ovarian cysts, twisted ovarian, and endometriosis
and gastroenteritis, peritonitis, and bacterial vaginosis among others. [1]
Pelvic inflammatory disease is more likely to reoccur when there is a prior history of the infection,
recent sexual contact, recent onset of menses, or an IUD (intrauterine device) in place or if the
partner has a sexually transmitted infection.[21]
Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place
or an IUD is not being used. A sensitive serum pregnancy test is typically obtained to rule out
ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy
or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured
appendix).[22]
Pelvic and vaginal ultrasounds are helpful in the diagnosis of PID. In the early stages of infection,
the ultrasound may appear normal. As the disease progresses, nonspecific findings can include
free pelvic fluid, endometrial thickening, uterine cavity distension by fluid or gas. In some
instances the borders of the uterus and ovaries appear indistinct. Enlarged ovaries accompanied
by increased numbers of small cysts correlates with PID. [22]
Laparoscopy is infrequently used to diagnose pelvic inflammatory disease since it is not readily
available. Moreover, it might not detect subtle inflammation of the fallopian tubes, and it fails to
detect endometritis.[23] Nevertheless, laparoscopy is conducted if the diagnosis is not certain or if
the person has not responded to antibiotic therapy after 48 hours. [citation needed]
No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. A
large multisite U.S. study found that cervical motion tenderness as a minimum clinical criterion
increases the sensitivity of the CDC diagnostic criteria from 83 percent to 95 percent. However,
even the modified 2002 CDC criteria do not identify women with subclinical disease. [24]

Prevention[edit]
Regular testing for sexually transmitted infections is encouraged for prevention. [25] The risk of
contracting pelvic inflammatory disease can be reduced by the following:

 Using barrier methods such as condoms; see human sexual behavior for other listings.[26]

 Seeking medical attention if you are experiencing symptoms of PID. [26]
 Using hormonal combined contraceptive pills also helps in reducing the chances of PID
by thickening the cervical mucosal plug & hence preventing the ascent of causative
organisms from the lower genital tract.[26]
 Seeking medical attention after learning that a current or former sex partner has, or might
have had a sexually transmitted infection. [26]
 Getting a STI history from your current partner and strongly encouraging they be tested
and treated before intercourse. [26]
 Diligence in avoiding vaginal activity, particularly intercourse, after the end of a
pregnancy (delivery, miscarriage, or abortion) or certain gynecological procedures, to ensure
that the cervix closes.[26]
 Sexual monogamy that restricts sexual activities to two 'virgins' or partners remaining
sexually exclusive with each other and having no outside sex partners. [27]
 Abstinence[26]

Treatment[edit]
Treatment is often started without confirmation of infection because of the serious complications
that may result from delayed treatment. Treatment depends on the infectious agent and generally
involves the use of antibiotic therapy. If there is no improvement within two to three days, the
patient is typically advised to seek further medical attention. Hospitalization sometimes becomes
necessary if there are other complications. Treating sexual partners for possible STIs can help in
treatment and prevention.[8]
For women with PID of mild to moderate severity, parenteral and oral therapies appear to be
effective.[28][29] It does not matter to their short- or long-term outcome whether antibiotics are
administered to them as inpatients or outpatients. [30] Typical regimens
include cefoxitin or cefotetan plus doxycycline, and clindamycin plus gentamicin. An alternative
parenteral regimen is ampicillin/sulbactam plus doxycycline. Another alternative is to use a
parenteral regimen with ceftriaxone or cefoxitin plus doxycycline. [21] Clinical experience guides
decisions regarding transition from parenteral to oral therapy, which usually can be initiated
within 24–48 hours of clinical improvement.[23]

Prognosis[edit]
Even when the PID infection is cured, effects of the infection may be permanent. This makes
early identification essential. Treatment resulting in cure is very important in the prevention of
damage to the reproductive system. Formation of scar tissue due to one or episodes of PID can
lead to tubal blockage, increasing the risk of the inability to get pregnant and long-term
pelvic/abdominal pain.[31] Since certain occurrences such as a post pelvic operation, the period of
time immediately after childbirth (postpartum),miscarriage or abortion increases the risk of
acquiring another infection leading to PID.[21]
Complications[edit]
PID can cause scarring inside the reproductive system, which can later cause serious
complications, including chronic pelvic pain, infertility, ectopic pregnancy (the leading cause of
pregnancy-related deaths in adult females), and other complications of pregnancy. Occasionally,
the infection can spread to in the peritoneum causing inflammation and the formation of scar
tissue on the external surface of the liver (Fitz-Hugh–Curtis syndrome).[32]

Epidemiology[edit]
Globally about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in
2008.[6] The number of cases of PID; however, is not clear. [10] It is estimated to affect about 1.5
percent of young women yearly.[10] In the United States PID is estimated to affect about one
million people yearly.[11] Rates are highest with teenagers and first time mothers. PID causes over
100,000 women to become infertile in the US each year.[33][34]

References[edit]
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